Skip to content

Dauntless Minds

lasting happiness starts here

about
get started
blog
declaration

Counseling Registration Page

Please complete the form below providing some information about yourself and what you are looking for. This will help me understand your challenges and specific needs. After considering your request, I will offer you an initial consultation. Your privacy is important.

Name *

First

Last

Address *

Post Code *

Email *

Phone *

What are the issues you seek to overcome? *

Building confidence and esteem
Resolving past trauma
Changing negative habits
Figuring out life direction
Help with relationships
Dealing with stress or depression
Anxiety & worry
Dealing with a loss
Self-development
Other

Have you ever been in counselling, therapy or coaching? If yes, please explain.

Name, address and phone number of your GP or family doctor. *

What medication are you currently taking (if applicable)? *

Have you or anyone in your family ever been diagnosed with a mental health problem (incl. eating disorders)? If yes, please explain. *

Have you ever attempted suicide? If yes, please explain. *

Are there any other medical issues we should be aware of? *

What are your hopes and expectations from counselling/coaching? *

Which days are you available? *

Any day is fine
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

What times are you available? *

Any time is fine
Morning (9am-noon)
Early afternoon (noon-3pm)
Late afternoon (3-6pm)
Evening (after 6pm)

What is your age? *

What is your gender? *

What is your relationship status? *

Consultations *

Counselling sessions will allow you to address issues you seek to solve. The counselling sessions will help you see things in new ways, but ultimately you remain responsible for any decisions you make or actions you take and the outcome of it.

Confidentiality *

Counselling is a professional and confidential relationship between you and your counsellor. Your counsellor agrees to keep your information private unless you give them specific permission to disclose it.

Limits to Confidentiality *

There are limits to the security of online conversations (type written) and via Skype. While your counsellor will not disclose any details to others, there is currently no guarantee that someone else cannot access (hack) a copy of online or Skype discussions.

Limits to Confidentiality *

If your counsellor comes to the conclusion that you or someone else may come to serious harm, they might advise you to contact your GP, Social Services etc. and if necessary, do so themselves. Also, there are situations when a counsellor is legally required to report information.

IMPORTANT: Your information remains confidential unless there is a risk to your personal safety or the safety of a child or vulnerable adult. By using the registration form, you agree to Dauntless Minds 'Privacy and Data Protection Policy' and how we protect and use your submitted information.

Terms of Payment *

All compensation is paid prior to the first session and is non-refundable. For individual session consultations you will be asked to set a Direct Debit. The consultation fees due will be debited from your account on the day of each appointment.

Cancelations / Changes *

If you need to cancel or reschedule a session please give as much notice as possible, at least 48 hours before you session. A cancelled, missed or changed appointment with less than 48 hour notice is charged the usual session fee.

With your name and today's date you indicate that you understand and agree with the above terms. *

First

Last

Today's date *

Website

Set Youtube Channel ID

Becoming Comfortably Confident

Upcoming Free - Your Life's Core Foundation

How to Gain and Maintain the Confidence & Clarity to get ANYTHING you dream of. On your terms.

I understand and agree to the marketing terms and conditions

Leave this field empty if you're human:

blog
about
Contact

Proudly powered by WordPress

HEAL & THRIVE

What would it be like to live more vibrantly from the Inside Out?

Any setback can be a trailhead to immense opportunities to heal our past trauma, change how we live in the present, and create a future based on who we truly are rather than who we expected to be.

CLICK to GET in TOUCH